Left ventricular hypertrophy as a determinant of renal outcome in patients with high cardiovascular risk

Obesity phenotypes and cardiovascular risk: From pathophysiology to clinical management

Obesity epidemic reached the dimensions of a real global health crisis with more than one billion people worldwide living with obesity. Multiple obesity-related mechanisms cause structural, functional, humoral, and hemodynamic alterations with cardiovascular (CV) deleterious effects. A correct assessment of the cardiovascular risk in people with obesity is critical for reducing mortality and preserving quality of life. The correct identification of the obesity status remains difficult as recent evidence suggest that different phenotypes of obesity exist, each one associated with different degrees of CV risk. Diagnosis of obesity cannot depend only on anthropometric parameters but should include a precise assessment of the metabolic status. Recently, the World Heart Federation and World Obesity Federation provided an action plan for management of obesity-related CV risk and mortality, stressing for the instauration of comprehensive structured programs encompassing multidisciplinary teams. In this review we aim at providing an updated summary regarding the different obesity phenotypes, their specific effects on CV risk and differences in clinical management.

Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome

Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.

Renal dysfunction in cardiovascular diseases and its consequences

It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.

Blood pressure and heart failure

Background

Hypertension is a leading cause of cardiovascular disease, stroke, and death. It affects a substantial proportion of the population worldwide, and remains underdiagnosed and undertreated.

Body

Long-standing high blood pressure leads to left ventricular hypertrophy and diastolic dysfunction that cause an increase in myocardial rigidity, which renders the myocardium less compliant to changes in the preload, afterload, and sympathetic tone. Adequate blood pressure control must be achieved in patients with hypertension to prevent progression to overt heart failure. Controlling blood pressure is also important in patients with established heart failure, especially among those with preserved ejection fractions. However, aggressive blood pressure lowering can cause adverse outcomes, because a reverse J-curve association may exist between the blood pressure and the outcomes of patients with heart failure. Little robust evidence exists regarding the optimal blood pressure target for patients with heart failure, but a value near 130/80 mmHg seems to be adequate according to the current guidelines.

Conclusion

Prospective studies are required to further investigate the optimal blood pressure target for patients with heart failure.

Risk Factors for Ischemic Heart Disease

BACKGROUND

Several risk factors have been empirically linked to an increased risk of cardiovascular disease. Some of them are therapeutically amenable to modification; while others are not. Modifiable risk factors include physical inactivity, tobacco use, diet, "bad fats" in the blood, hypertension, and being overweight; while non-modifiable risk factors include the patient's family history, the presence versus absence of diabetes mellitus, and demographic characteristics like age, gender, ethnicity, and socio-economic status.

METHODS

In this article, we review those risk factors that are both clinically important and amenable to change.

CONCLUSION

To prevent cardiovascular disease, it is important to minimize modifiable risk factors, like LDL cholesterol.

Long-Term Effects of Intensive Glycemic and Blood Pressure Control and Fenofibrate Use on Kidney Outcomes

BACKGROUND AND OBJECTIVES

In people with type 2 diabetes, aggressive control of glycemia, BP, and lipids have resulted in conflicting short-term (<5 years) kidney outcomes. We aimed to determine the long-term kidney effects of these interventions.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) was a multifactorial intervention study in people with type 2 diabetes at high risk for cardiovascular disease (n=10,251), to examine the effects of intensive glycemic control (hemoglobin A1c <6.0% versus 7%-7.9%), BP control (systolic BP <120 mm Hg versus <140 mm Hg) or fenofibrate versus placebo added to simvastatin on cardiovascular events and death. The glycemia trial lasted 3.7 years and participants were followed for another 6.5 years in ACCORDION, the ACCORD Follow-On Study. The post hoc primary composite kidney outcome was defined as incident macroalbuminuria, creatinine doubling, need for dialysis, or death by any cause. Cox proportional hazards regression estimated the effect of each intervention on the composite outcome and individual components. In secondary outcome analyses, competing risk regression was used to account for the risk of death in incident kidney outcomes. Analyses were adjusted for sociodemographics, randomization groups, and clinical factors.

RESULTS

There were 988 cases of incident macroalbuminuria, 954 with doubling of creatinine, 351 requiring dialysis, and 1905 deaths. Hazard ratios (HRs) for the composite outcome with intensive glycemic, BP control, and fenofibrate use compared with standard therapy were 0.92 (95% confidence interval [95% CI], 0.86 to 0.98), 1.16 (95% CI, 1.05 to 1.28), and 1.16 (95% CI, 1.06 to 1.27). Multivariable, secondary outcome analyses showed that in the glycemia trial, only macroalbuminuria was significantly decreased (HR, 0.68; 95% CI, 0.59 to 0.77). In the BP and lipid trials, only creatinine doubling was affected (HR, 1.64; 95% CI, 1.30 to 2.06 and HR, 2.00; 95% CI, 1.61 to 2.49, respectively).

CONCLUSIONS

In people with type 2 diabetes at high risk for cardiovascular disease, intensive glycemic control may result in a long-term reduction in macroalbuminuria; however, intensive BP control and fenofibrates may increase the risk for adverse kidney events.

Value of reduced glomerular filtration rate assessment with cardiometabolic index: insights from a population-based Chinese cohort

BACKGROUND

Recent studies have suggested that cardiometabolic index (CMI), a novel estimate of visceral adipose tissue, could be of use in the evaluation of cardiovascular risk factors. However, the potential utility and clinical significance of CMI in the detection of reduced estimated glomerular filtration rate (eGFR) remains uncertain. The purpose of this study was to investigate the usefulness of CMI in assessing reduced eGFR in the general Chinese population.

METHODS

This cross-sectional analysis included 11,578 participants (mean age: 53.8 years, 53.7% females) from Northeast China Rural Cardiovascular Health Study (NCRCHS) of general Chinese population (data collected from January 2013 to August 2013). CMI was calculated by triglyceride to high density lipoprotein cholesterol ratio multiply waist-to-height ratio. Reduced eGFR was defined as eGFR< 60 ml/min per 1.73m2. Multivariate regressions were performed to determine CMI's association with eGFR value and eGFR reduction, ROC analyses were employed to investigate CMI's discriminating ability for decreased eGFR.

RESULTS

The prevalence of reduced eGFR was 1.7% in males and 2.5% in females. CMI was notably more adverse in reduced eGFR groups, regardless of genders. In fully adjusted multivariate linear models, each 1 SD increment of CMI caused 3.150 ml/min per 1.73m2 and 2.411 ml/min per 1.73m2 loss of eGFR before CMI reached 1.210 and 1.520 in males and females, respectively. In logistic regression analyses, per 1 SD increase of CMI brought 51.6% additional risk of reduced eGFR in males while caused 1.347 times of risk in females. After divided into quartiles, people in the top quartile of CMI had higher adjusted ORs of having reduced eGFR, with ORs of 4.227 (1.681, 10.627) and 3.442 (1.685-7.031) for males and females respectively. AUC of CMI was revealed to be 0.633 (0.620-0.646) in males and 0.684 (0.672-0.695) in females.

CONCLUSIONS

Higher CMI was independently associated with greater burden of reduced eGFR, highlighting VAT distribution and dysfunction as a potential mechanism underlying the association of obesity with kidney damage and adverse cardiovascular outcomes. The findings from this study provided important insights regarding the potential usefulness and clinical relevance of CMI in the detection of reduced eGFR among general Chinese population.

Increased Serum Uric Acid Level Is a Risk Factor for Left Ventricular Hypertrophy but Not Independent of eGFR in Patients with Type 2 Diabetic Kidney Disease

BACKGROUND

Although the relation between serum uric acid (SUA) and left ventricular hypertrophy (LVH) has been studied for decades, however, their association remains debatable.

METHODS

This is a retrospective study in which a total of 435 hospitalized Chinese patients with type 2 DKD were enrolled. The subjects were stratified into quartiles according to SUA level. LVH was assessed by two-dimensional guided M-mode echocardiography.

RESULTS

There was a significant increase in the prevalence of LVH in patients with type 2 DKD across SUA quartiles (28.9, 26.5, 36.1, and 49.5%; p < 0.001). The Spearman analysis indicated that SUA was positively correlated to LVMI and negatively correlated to eGFR. The logistic regression analysis revealed that the odd ratio for LVH in the highest SUA quartile was 2.439 (95% CI 1.265-4.699; p = 0.008; model 1) or 2.576 (95% CI 1.150-5.768; p = 0.021; model 2) compared with that in the lowest SUA quartile. However, there was no significant increased risk of LVH in the subjects with the highest SUA quartile after adjusting the eGFR (OR = 1.750; 95% CI 0.685-4.470; p = 0.242; model 3).

CONCLUSIONS

In selected population, such as type 2 DKD, the elevated SUA level is positively linked with the increased risk of LVH, but this relationship is not independent of eGFR.

Aging Male Spontaneously Hypertensive Rat as an Animal Model for the Evaluation of the Interplay between Contrast-Induced Acute Kidney Injury and Cardiorenal Syndrome in Humans

BACKGROUND

Although there are some animal models for biomarkers of contrast-induced acute kidney injury (CI-AKI), for cardiorenal syndrome (CRS) and for acute renal failure, the interplay between CI-AKI and CRS has yet to be evaluated. Insight into the pathogenesis of CRS is urgently needed from animal models in order to foster the discovery and implementation of novel biomarkers for this disease. Specially designed animal models for type 1 and 3 CRS, particularly CI-AKI, have not yet emerged.

SUMMARY

We hypothesize that the aging male spontaneously hypertensive rat (SHR) is likely to be a suitable model. The SHR model is able to mimic risk factors for preclinical CRS that appears in the clinical setting, specifically hypertension, age, preexisting damage and dysfunction of the heart and kidney, endothelial dysfunction, increased level of reactive oxygen species, decreased level and bioavailability of nitric oxide (NO), impairment of the L-arginine-NO pathway, and insulin resistance. In the SHR, CI-AKI results in a different profile of AKI biomarkers than is seen with preexisting chronic kidney injury.

KEY MESSAGES

The SHR model can be used to evaluate the interaction between CI-AKI and CRS type 1 and 3 and to verify neutrophil gelatinase-associated lipocalin (NGAL) as a reliable CI-AKI biomarker for clinical application. Further research is warranted with a large number of aging male SHRs to prove NGAL as a sensitive, specific, highly predictive, early biomarker for CI-AKI.

Association of Endothelial and Mild Renal Dysfunction With the Severity of Left Ventricular Hypertrophy in Hypertensive Patients

BACKGROUND

The association between impaired renal function and increase left ventricular mass was shown to be related to increase in arterial stiffness, which indicates that vascular homeostasis and remodeling may impact the left ventricular hypertrophy (LVH) in patients with renal dysfunction.

METHODS

We measured the peripheral arterial reactive hyperemia index (RHI) and estimated glomerular filtration rate (eGFR) in 317 hypertensive patients comprising 115 normal RHI (RHI > 1.67) and normal eGFR (eGFR ≥ 90ml/min per 1.73 m(2)), 136 low RHI (RHI ≤ 1.67), 27 low eGFR (60 ≤ eGFR < 90ml/min per 1.73 m(2)) and 39 low RHI combined with low eGFR.

RESULTS

Multivariate logistic regression analysis identified lg RHI (odds ratio (OR): 0.001, 95% confidence interval (CI): 10(-6) to 0.426, P = 0.024) and lg eGFR (OR: 0.009, 95% CI: 10(-4) to 0.414, P = 0.016) as independent factors correlated with LVH respectively in hypertensive patients. Compared with normal RHI and eGFR patients, the extent of LVH in patients with either low RHI (OR: 1.224 95% CI: 0.451 to 3.327, P = 0.691) or low eGFR (OR: 0.593 95% CI: 0.070 to 5.037, P = 0.632) did not significantly increase, while it increased significantly in patients with low RHI combined with low eGFR (OR: 4.629 95% CI: 1.592 to 13.458, P = 0.005).

CONCLUSIONS

The concurrence of endothelial and mild renal dysfunction was significantly associated with the severity of LVH in hypertensive patients.

Left ventricular mass and systolic function in children with chronic kidney disease-comparing echocardiography with cardiac magnetic resonance imaging

BACKGROUND

Increased left ventricular mass (LVM) is an important risk marker of uremic cardiovascular disease. Calculation of LVM by echocardiography (Echo) relies on geometric assumptions and in adults on hemodialysis overestimates LVM compared to cardiac magnetic resonance (CMR). We compare both techniques in children with chronic kidney disease (CKD).

METHODS

Concurrent Echo and CMR was performed in 25 children with CKD (14 after kidney transplantation) aged 8-17 years.

RESULTS

Compared to normal children, CMR-LVM was increased (standard deviation score (SDS) 0.39 ± 0.8 (p = 0.03)), stroke volume and cardiac output decreased (SDS -1.76 ± 1.1, p = 0.002 and -1.11 ± 2.0, p = 0.001). CMR-LVM index but not Echo-LVMI correlated to future glomerular filtration rate (GFR) decline (r = -0.52, p = 0.01). Mean Echo-LVM was higher than CMR-LVM (117 ± 40 vs. 89 ± 29 g, p < 0.0001), with wide limits of agreement (-6.2 to 62.8 g). The Echo-CMR LVM difference increased with higher Echo-LVMI (r = 0.77, p < 0.0001). Agreement of classifying left ventricular hypertrophy was poor with Cohen's kappa of 0.08. Mean Echo and CMR-ejection fraction differed by 1.42% with wide limits of agreement (-12.6 to 15.4%).

CONCLUSIONS

Echo overestimates LVM compared to CMR, especially at higher LVM. Despite this, CMR confirms increased LVM in children with CKD. Only CMR-LVMI but not Echo-LVMI correlated to future GFR decline.

Cumulative Effects of Several Target Organ Damages in Risk Assessment in Hypertension

BACKGROUND

The prognostic value of screening multiple target organ damages (TODs) in hypertensive subjects has not been extensively studied. We estimated the prognostic value of considering 3 TODs in estimating the 10-year survival in hypertensive subjects.

METHODS

At baseline 1,848 out of a cohort of 1,963 hypertensive patients had a previous cardiovascular disease (CVD) or assessments of 3 TODs: Modification in Diet in Renal Disease (MDRD) <60ml/min or albuminuria >300mg/day, Sokolow index >3.5 mV, and advanced hypertensive retinopathy (grades 3 and 4 of Keith-Wagener-Barker classification). The cohort was divided into 5 groups: 0 TOD (N = 978), 1 TOD (N = 308), 2 TODs (N = 94), 3 TODs (N = 30), and previous CVD (N = 438).

RESULTS

After 10 years of follow-up, we observed 418 deaths of which 254 from cardiovascular cause. The adjusted hazard ratios for the major cardiovascular risk factors showed a progressive risk associated with the number of TODs. For all-cause death, the hazard ratios [95% confidence intervals] vs. 0 TOD of the other 4 groups were 1.91 [1.39-2.63], 1.99 [1.28-3.10], 4.33 [2.42-7.72], and 3.09 [2.35-4.05], respectively. For cardiovascular death, the hazard ratios [95% confidence intervals] were of the same order of magnitude: 2.14 [1.38-3.32], 2.12 [1.15-3.89], 4.22 [1.83-9.72], and 4.24 [2.95-6.11], respectively.

CONCLUSIONS

Our results indicate that hypertensive patients with several TODs had a worst outcome. Thus, it seems important to screen for multiple TODs in hypertension; especially check for severe hypertensive retinopathy in patients with left ventricular hypertrophy (LVH) and renal damage.

Serum cystatin C level is associated with left atrial enlargement, left ventricular hypertrophy and impaired left ventricular relaxation in patients with stage 2 or 3 chronic kidney disease

BACKGROUND

Cystatin C is an endogenous marker of kidney function that overcomes the limitations of serum creatinine. High serum cystatin C levels have been associated with increased cardiovascular mortality and morbidity. In this cross-sectional study, we aimed to determine the associations between serum cystatin C levels and structural and functional cardiac changes in patients with stage 2 or 3 chronic kidney disease (CKD).

METHODS AND RESULTS

We enrolled 429 consecutive patients (aged 24-97 years) with CKD stage 2 or 3 and left ventricular (LV) ejection fraction (LVEF)>40%. Echocardiographic parameters, including LV mass index (LVMI), early diastolic mitral annulus velocity (e' velocity), left atrial volume index (LAVI), and N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) were measured. Patients were categorized into quartiles according to serum cystatin C levels. Cystatin C was associated with LAVI (p=0.0055), LVEF (p=0.0432), LVMI (p=0.0409), e' (p=0.0051), E/e' (p=0.0027), and log-transformed NT-proBNP (p<0.0001) according to multivariate linear regression analysis, after adjustment for confounding factors including creatinine-based estimated glomerular filtration rate (eGFRcreat) and urinary albumin to creatinine ratio. Incidence of eccentric and concentric hypertrophy increased with increasing cystatin C (Q1, 38%; Q2 49%; Q3, 51%; Q4, 66%, p=0.0008), mainly because of increasing concentric hypertrophy (Q1, 30%; Q2, 39%; Q3, 39%; Q4, 51%, p=0.0187).

CONCLUSION

A high serum cystatin C is strongly associated with structural cardiac abnormalities such as LVH and left atrial enlargement, impaired LV relaxation, and an increased NT-proBNP, independently of eGFRcreat in patients with stage 2 or 3 CKD.

Dynamic resistant hypertension patterns as predictors of cardiovascular morbidity: a 4-year prospective study

OBJECTIVE

Little is known regarding the clinical course and prognosis of resistant hypertension (RHT). We evaluated predictors of persistent RHT and the associated cardiovascular risk.

METHODS

We studied 1911 treated hypertensive patients (aged 59±11 years, 49% men) for a mean period of 3.9 years. At baseline, clinical data were collected and patients underwent echocardiographic measurements, routine blood testing and additional workup for exclusion of secondary causes of RHT (office-based uncontrolled hypertension under at least three drugs including a diuretic or controlled hypertension under four or more drugs). Endpoint of interest was the composite of coronary artery disease and stroke.

MAIN RESULTS

Four groups were identified depending on presence or absence of RHT at baseline and follow-up: 1153 patients (60%) never having RHT, 189 (10%) with resolved RHT, 204 (11%) with incident RHT and 365 (19%) with persistent RHT. Two-thirds of the patients with RHT at baseline remained resistant at the end of the study. Independent variables associated with both incident and persistent RHT were diabetes mellitus, history of cardiovascular disease, hypertension duration, SBP, left ventricular hypertrophy and glomerular filtration rate. Persistent RHT compared with never-having RHT was associated with a 2.2-fold increased risk for cardiovascular morbidity (95% CI: 1.21-4.05, P = 0.01) after adjustment for risk factors.

CONCLUSION

In treated hypertensive patients, among prospective RHT dynamic patterns, persistent RHT is frequent and independently associated with adverse cardiovascular prognosis.

Subclinical nephrosclerosis is linked to left ventricular hypertrophy independent of classical atherogenic factors

Recently, cardio-renal interactions have been considered to be important and it has been demonstrated that mild renal dysfunction is associated with left ventricular hypertrophy (LVH). However, the correlation between LVH and subclinical renal damage is unclear. We investigated this association by assessing pretransplant biopsies from living kidney donors with normal renal function. We retrospectively categorized 238 living kidney donors into tertiles according to the percentage of global glomerulosclerosis (%GGS) observed in pretransplant biopsies (low, 0-3.45% (n=80); moderate, 3.46-11.76% (n=78); high, ⩾11.77% (n=80)) to analyze trends in their left ventricular mass index (LVMI) measured by echocardiography and baseline factors. LVH was defined as LVMI >110 g m(-2) in female and >125 g m(-2) in male subjects. We used a logistic regression model to evaluate any correlations between %GGS and LVH. LVMI increased significantly with increasing tertiles of %GGS, as did the prevalence of left ventricular remodeling and LVH. According to multivariate logistic regression analysis, subjects with high %GGS tertiles had a sevenfold greater risk of LVH than did those with low tertiles, even after adjusting for age, sex, systolic blood pressure, history of diabetes mellitus, total serum cholesterol and glomerular filtration rate (GFR) measured by a radioisotopic technique. There is an association between GGS and LVH in subjects with normal renal function. This association is significant after adjustment for age, sex, blood pressure, GFR and other atherogenic factors.

A look at the upper heart chamber: the left atrium in chronic kidney disease

Altered left ventricular (LV) mass and function are classical hallmarks of cardiomyopathy in chronic kidney disease (CKD). The left atrium (LA), a heart chamber exquisitely sensitive to volume overload and diastolic function, is an independent predictor of death and adverse cardiovascular (CV) events in high-risk patients such as those with hypertension and/or with heart failure. In this review we focus on the relationship of LA size with LV diastolic function, and the association between LA enlargement and CV and renal outcomes in patients with CKD, including patients with end-stage renal disease. Increased LA size emerges as a powerful predictor of mortality and major adverse CV events in both end-stage and early CKD, and some studies also show a close association between enlarged LA and renal disease progression. Secondary analyses of clinical trials suggest that the LA has the potential to be elected as a surrogate end point in CKD patients but the issue remains to be tested in specifically designed clinical studies.

Preclinical cardiorenal interrelationships in essential hypertension

A diseased heart causes numerous adverse effects on kidney function, and vice versa renal disease can significantly impair cardiac function. Beyond these heart-kidney interrelationships at the clinical level, a reciprocal association has been suggested to exist even in the early stages of those organs' dysfunction. The aim of the present review is to provide evidence of the presence of a preclinical cardiorenal syndrome in the particular setting of essential hypertension, focusing on the subsequent hypertensive sequelae on heart and kidneys. In particular, a plethora of studies have demonstrated not only the predictive role of kidney damage, as expressed by either decreased glomerular filtration or increased urine albumin excretion, for adverse left ventricular functional and structural adaptations but also preclinical heart disease, i.e. left ventricular hypertrophy that is associated with deterioration of renal function. Notably, these reciprocal interactions seem to exist even at the level of microcirculation, since both coronary flow reserve and renal hemodynamics are strongly related with clinical and preclinical renal and cardiac damage, respectively. In this preclinical setting, common pathophysiological denominators, including the increased hemodynamic load, sympathetic and renin-angiotensin system overactivity, increased subclinical inflammatory reaction, and endothelial dysfunction, account not only for the reported associations between overt cardiac and renal damage but also for the parallel changes that occur in coronary and renal microcirculation.

Left-ventricular hypertrophy and renal outcome in hypertensive patients in primary-care

BACKGROUND

Subclinical cardiac damage has recently emerged as a potential predictor of adverse renal outcome. We therefore retrospectively evaluated the effect of left-ventricular hypertrophy (LVH), diagnosed electrocardiographically, on the renal outcome of hypertensive patients managed in primary care.

METHODS

From a historical cohort of 39,525 hypertensive individuals evaluated in 2005, we retrieved 5-year data of the 18,510 surviving subjects for whom renal follow-up was available.

RESULTS

The baseline prevalences of chronic kidney disease (CKD) and LVH in the study cohort were 25.6% and 5.6%, respectively. During the 5-year follow-up, 1.4% of patients with LVH and 0.5% of those without LVH progressed to end-stage renal disease (ESRD) requiring dialysis (P < 0.01). Moreover, 25.6% of patients with LVH and 17% without LVH progressed from each stage of CKD to a more advanced stage (P < 0.01), whereas 0.9% of patients with LVH and 0.4% without LVH reached stage 5 CKD (P < 0.01). Multivariate Cox regression analysis showed that besides estimated glomerular filtration rate (eGFR) and male gender, LVH was the most significant modifiable predictor of progression to dialysis (hazard ratio (HR), 1.82; 95% CI, 1.05-3.17; P = 0.03). Multivariate logistic regression analysis also revealed LVH as a significant predictor of the risk of progression from each stage of CKD to a more advanced stage (OR, 1.24; 95% CI, 1.07-1.45; P < 0.01), as well as of progression to stage 5 CKD (OR, 1.86; 95% CI, 1.17-2.95; P < 0.01).

CONCLUSIONS

Left-ventricular hypertrophy proved to be a significant predictor of adverse renal outcome in hypertensive patients managed with primary care, and systematic screening for LVH should be adopted for assessing renal risk in these patients.

Left ventricular mass index as a predictor of new-onset microalbuminuria in hypertensive subjects: a prospective study

BACKGROUND

We aimed to investigate the predictive role of left ventricular mass and its reduction on the development of new-onset microalbuminuria (MA) in newly diagnosed hypertensive patients.

METHODS

A total of 207 nondiabetic, normoalbuminuric patients without clinical organ damage (aged 50.8 ± 10.1 years, 132 male, 84 smokers) with baseline office blood pressure (BP) 148/96 mm Hg were followed for a mean period of 3.3 ± 1.3 years. At baseline and last follow-up visit, all patients underwent office and 24-h ambulatory BP monitoring, albumin to creatinine ratio (ACR) determination, and echocardiographic assessment of left ventricular mass index (LVMI). All patients were treated with antihypertensive therapy during the follow-up period. We defined MA as ACR between 20 and 300 mg/g for men and 30-300 mg/g for women, effective BP control as office BP <140/90 mm Hg in ≥75% of total number of visits, and LVMI reduction as the decline of LVMI at end-follow-up of ≥15% with respect to the baseline value.

RESULTS

Between baseline and last follow-up visit, LVMI decreased by 6.84 ± 21.5 g/m(2) (P < 0.01); 64.3% (n = 133) of participants achieved BP control during the follow-up period. Of the total population, 5.8% (n = 12) developed MA during follow-up. Cox-regression analysis, after adjustment for clinical variables, revealed that increase of LVMI by 1 s.d. (23.3 g/m(2)) conferred a 15% increased risk of new-onset MA, while LVMI reduction and BP control were both associated with almost 100% reduced risk of MA development.

CONCLUSIONS

LVMI and its reduction were qualified as predictors of new-onset MA in newly diagnosed hypertensive patients, beyond BP control.

Non-dipper status and left ventricular hypertrophy as predictors of incident chronic kidney disease

We have hypothesized that non-dipper status and left ventricular hypertrophy (LVH) are associated with the development of chronic kidney disease (CKD) in non-diabetic hypertensive patients. This study included 102 patients with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m(2). Ambulatory blood pressure monitoring and echocardiography were performed at the beginning of the study, and the serum creatinine levels were followed. During the average follow-up period of 51 months, CKD developed in 11 patients. There was a significant difference in the incidence of CKD between dippers and non-dippers (5.0% vs 19.0%, P < 0.05). Compared to patients without CKD, patients with incident CKD had a higher urine albumin/creatinine ratio (52.3 ± 58.6 mg/g vs 17.8 ± 29.3 mg/g, P < 0.01), non-dipper status (72.7% vs 37.4%, P < 0.05), the presence of LVH (27.3% vs 5.5%, P < 0.05), and a lower serum HDL-cholesterol level (41.7 ± 8.3 mg/dL vs 50.4 ± 12.4 mg/dL, P < 0.05). Based on multivariate Cox regression analysis, non-dipper status and the presence of LVH were independent predictors of incident CKD. These findings suggest that non-dipper status and LVH may be the therapeutic targets for preventing the development of CKD in non-diabetic hypertensive patients.